Advances in verbal autopsy: pragmatic optimism or optimistic theory?
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COMMENTARY
Open Access
Advances in verbal autopsy: pragmatic optimism or optimistic theory? Edward Fottrell1,2 Commentary In recent decades, verbal autopsy (VA) methods have been increasingly used to identify likely causes of death in settings where the majority of deaths occur without medical attention or certification as to cause [1]. Developments in the 1980s and 1990s advanced the conceptual and methodological aspects of the science considerably but fell short of providing a clear message about best practices for those who rely on VA data [2-10]. There has been a hiatus of methodological development since then, due in part to persistent, narrow assumptions as to the desire and need for cause of death data and unrealistic evaluation standards. This has not limited the application of VA methods in the world’s poorest settings, but it has almost certainly limited the usefulness and comparability of the data. There remains scarce evidence on which to base choice of methods at the various stages of the VA data process. However, the first ever Global Congress on Verbal Autopsy, held in Bali, Indonesia in February 2011, represents a resurgence of methodological and conceptual developments - VA is arguably one of the most important fields in global health today. Methodological development in recent years, particularly in relation to probabilistic interpretation of VA data, has brought VA into an exciting era that is creating new opportunities for reliable, timely, and useful cause-specific mortality measurement. A shift away from limited individual-level and clinical paradigms towards population-based epidemiological thinking and public health utility has been characterized by a flurry of new methodological thinking and innovations from relatively small groups of researchers. Among these like-minded researchers, however, there is risk of a divide between pragmatic optimists and optimistic theorists. The pragmatic optimists are driven by the realities, perils, and Correspondence: [email protected] 1 Umeå Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umeå University, Sweden Full list of author information is available at the end of the article
pitfalls of real-life health measurement in low-income settings and strive to enhance health knowledge with methods that are good enough to fill data gaps reliably and efficiently. The optimistic theorists, whose methodological developments are often theoretically superior, are often far from offering practical solutions to those on the ground who need to know the major burdens of cause-specific mortality in their populations simply, quickly, and cheaply in the absence of pre-existing data and where “true validity” is difficult to establish. Such dichotomization is perhaps somewhat artificial, but there is a real risk that unrealistic standards and expectations in method development and evaluation will become the enemy of good enough methods that are able to provide essential data to those who need it. The Global Congress on VA
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